Study: OUD Patients More Likely to Stay on Methadone Than Buprenorphine/Naloxone

Patients with opioid use disorder (OUD) had a lower risk of discontinuing methadone compared with buprenorphine/naloxone, and with a similar mortality risk, according to a population-based cohort study published in JAMA.

In this video interview, researcher Bohdan Nosyk, PhD, of Simon Fraser University in Burnaby, British Columbia, discusses the findings and their implications for public policy.

The following is a transcript of his remarks:

Our objective was to use all of B.C.’s [British Columbia’s] linked provincial health administrative data, keeping in mind it’s a universal healthcare system, single-payer system, so we truly do have a full population. And we wanted to compare the performance of the two primary modes of treatment for opioid use disorder that we have, so aqueous methadone and buprenorphine/naloxone.

I’ll preface this by saying two things. First, unlike the U.S., methadone and buprenorphine/naloxone are available in both office-based settings and specialized drug treatment centers. That differs from the U.S., where methadone isn’t available in office-based settings.

Second, buprenorphine/naloxone was made first-line treatment here in B.C. unlike anywhere else in the world in 2017. So I think it’s a relevant question to ask both locally for our local clinical guidelines as well as in the U.S., and the fact that both treatments are offered in the same kinds of settings allows for direct comparison.

What we found was [with] methadone, people had a much easier time remaining on treatment. Their discontinuation rate was substantially lower — 35% to 40% lower — on methadone compared to buprenorphine. And the risk of mortality while people were on treatment was no different; we didn’t see a statistically significant difference.

That finding is important both locally and internationally. It, I think, provides a strong impetus to make methadone available in office-based settings in the U.S. since it outperformed buprenorphine.

Locally, the decision to make buprenorphine first-line treatment was [due to] a greater safety profile, and while the advantage was to buprenorphine slightly, even over 10 years we couldn’t see a meaningful difference. That should persuade more and more clinicians to turn to methadone.

The other piece of context I want to raise is that fentanyl was first detected in B.C. in 2012, and it’s taken over our opioid supply. That is a far more potent opioid, so people have much higher tolerance and you need higher doses to eliminate withdrawal symptoms, which is the goal of opioid agonist treatment. And so really, I think what our results are telling us is that methadone is really the preferred option in the fentanyl era.

A study clearly showing with an apples-to-apples comparison an advantage towards methadone I think makes a strong case to make it available in all settings. And I know that’s of interest. Not allowing methadone to be prescribed in office-based settings, it’s just taking a tool out of use for you in the U.S. So I really hope it’s going to be helpful. I know the NIH was interested in this study for that reason. They needed evidence, observational evidence, true population-based observational evidence, to compare performance in these medications.

The notion of how we treat people with opioid use disorders really needs to be reexamined. A lot has been static for a long time, and these clinical guidelines have been based on evidence drawn from the heroin era, pre-fentanyl era. So we hope this study spurs a lot more similar work along these lines.

Just by virtue of some of the policy changes we’ve made here, we’re now seeing things like combination OAT [opioid agonist therapy], people prescribing short-acting opioids alongside a backbone of methadone has shown benefits, fentanyl patches. We need to think about how if people are using benzodiazepines along with their opioids, we need to be thinking about how to treat [benzodiazepines] and opioid co-use. Whether that requires a short taper, a long taper — none of these questions have yet been answered.

So I think treatment of opioid use disorders, pharmacotherapies for opioid use disorders need to keep up with the changing illicit drug supply. That’s really our focus moving forward.

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